World Stroke Day

Philip Hollobone Excerpts

Thursday 23rd November 2023 Westminster Hall

[Sir Robert Neill]

That is right and that is why I commend the Stroke Association for raising awareness and recognition of symptoms. It promotes the Act FAST campaign, which details the symptoms that should be looked out for: if someone shows facial weakness, arm weakness or speech problems, then it is time to call 999. That has been important in raising awareness. I thank the Stroke Association for the briefing it has provided, as well as others who have assisted in the preparation of my comments, including the Royal College of Radiologists and, from the private sector, Ipsen UK, a biopharmaceutical company that works in this field. I will refer to its research.

The essence of the matter is this: stroke is not often recognised, but even when it is, the quantity is not talked about enough. In the UK, stroke strikes every five minutes and more than 100,000 people have strokes every year. It is a leading cause of adult disability; two thirds of stroke survivors leave hospital with a disability. Sadly, it is also a leading cause of death in the UK. Leaving aside the human cost, there is also an economic cost. Too many survivors are unable to return to work. A conservative estimate of the cost to the economy is some £26 billion a year. Some would suggest that it is even more. Never mind the care costs and the burdens on unpaid carers, which some of us know all too well.

Stroke is preventable. In about 80% of cases, it can be treated by changing risk factors, checking for high blood pressure and atrial fibrillation, but we still lag behind other countries on stroke outcomes. The Stroke Association told me that, for every minute a stroke is left untreated, nearly 2 million brain cells die. The brain is both extraordinary and fragile, which is why fast treatment and swift responses are so important. That means getting somebody to a specialist stroke unit as soon as possible. In Anne-Louise’s case, we were lucky that that was not far away, but sadly there will always be disability thereafter. However, that can be reduced through investment in treatments, such as mechanical thrombectomy. If a patient gets mechanical thrombectomy swiftly, their level of impairment is greatly reduced.

Sadly, access to mechanical thrombectomy greatly varies across the country. In Greater London, where my constituency is, the percentage of patients given a thrombectomy in 2021—there may be updated figures, but this is the latest one the Stroke Association had—was 7.8%. In the east of England, it was 0.3%. In most other parts of the country, it hovers around 2%. Even if that has grown somewhat, it is still far less than we would wish to see. I welcome the Minister and am grateful to see him in his place, and I am sure that he is aware that investment across the piece would greatly improve people’s outcomes. That needs to be mainstreamed into investment plans, and we certainly seek to do that. I hope the Minister will commit to removing that postcode lottery in survival according to where a person is when they have the misfortune of having a stroke. If we do not do anything about this, the cost I referred to is predicted to increase to about £75 billion by 2035. We cannot afford for that to happen, either economically or in human terms.

We have talked about prevention and thrombectomies, which can be a game changer, but we do not have anything like the numbers accessing them that other countries do and the figures are not in line with the Government’s own targets. Perhaps the Minister could tell us what is being done to catch up and spread availability across the piece, because at the moment only about a third of the people who need that treatment receive it. That is simply not good enough for the two thirds that were unlucky enough to be in the wrong place at the wrong time. That is important, but there is also the issue of the workforce. I am indebted to the Royal College of Radiologists on this point. Early diagnosis, of course, can help through either thrombectomy or other interventions, but we have a shortfall in the number of clinical radiology consultants of some 30%. They are needed to do the imaging—the MRIs and all the other things—that could enable those other treatments to take place swiftly. Without further action, that shortfall of consultants in radiology is forecast to increase to 41% by 2027—2,890-odd posts. What is being done to address the shortfall in that specialism and, indeed, others?

Only 48% of hospital trusts can provide adequate 24/7 interventional radiology services, largely because of that workforce shortage. I am sure the Minister will once again agree that that is not satisfactory. The use of interventional radiology—image-guided surgical treatments, effectively—is critical in the modern treatment of strokes. When we look at the national health service’s workforce plan, what are the plans specifically to recruit the workforce—the skilled specialists we need to support those new procedures, which will save lives and improve lives for survivors?

As well as the key issues of intervention and treatment, the other issue I want to touch on is what happens thereafter, because the outcomes can vary greatly. Some people, as we all know, are fortunate enough to be out of hospital quite quickly, whereas others—my wife included—spend much longer there. What troubled me was when Anne-Louise eventually left the rehabilitation unit in Orpington, where she had excellent care, we were lucky enough to be able to continue care at a proper level, through our own resources as a family. There was a young woman in there, probably in her mid-40s, who was a single parent. She lived on her own and had no one to take care of her. She was there before Anne-Louise arrived in the unit; she was still there when Anne-Louise left. What happens to someone in that condition is a real worry to us.

I am sure the Minister will rightly observe that the percentage of patients discharged into community stroke services has risen from 53% to 61% in 2022-23, but the quality and consistency of the community service provision is very variable. There are real shortfalls in the number of specialists—again—so we have a workforce problem in the community as well when it comes to physiotherapists, speech and language therapists and neuropsychiatrists.

We sometimes forget that, as well as the very real physical impacts of stroke—which can be a lack of mobility or balance, a level of paralysis, speech impairment and post-stroke spasticity, as it is called, which I will come back to in a moment—there is very frequently a degree of mental ill health associated with such a life-changing event. Many stroke survivors suffer from varying degrees of depression, and the lack of neuropsychiatrists and psychologists to assist them is very stark.

We know that nearly half of stroke survivors experience some degree of post-stroke spasticity within six months of having a stroke, and some will be classed as severely disabled. We then find that some 80% of survivors may develop it at some point unless they get that proper and consistent treatment. At the moment, we do not deliver the recommended levels of community care in the therapies, of all kinds, that are recommended by the nationally accepted guidelines. What is being done to improve that?

At the moment, in the community setting, post-stroke patients experiencing post-stroke spasticity may have to wait four to seven months to be seen for a multi- disciplinary-team assessment. That is far too long. I have a constituent who has been waiting for nearly a year to be assessed to receive the multidisciplinary treatment that she needs. Accessing that support surely should not be done on such a fragile basis.

Ipsen has recently published a report, “Neuro- rehabilitation: State of the Nation”, which discusses this issue. It found that there is a lack of foundational awareness about spasticity and that it is not picked up often or soon enough. In fact, there are issues with the sporadic nature of treatment and a five to six months average waiting time for spasticity services. One in four NHS sites in England do not have access to specialist services for spasticity—there are only 0.26 consultants per 1,000 in prescribed specialist services in England and Wales compared with two to three in most European countries. Something like two in three stroke survivors do not receive a six-month review of their care, and that is one of the fundamental targets set out in the national guidelines. If two thirds are not receiving it, then clearly something is failing us badly.

We would like the Government to designate stroke as a major condition, and they also ought to consider post-stroke spasticity management as an integral part of the major conditions strategy. Perhaps the Minister will take that away and consider it. What can be done to level up the commissioning and provision of those rehabilitation services? What can be done to look at the high-level priority areas for stroke research that have been identified? These are important matters and we would hope that that could be done. There are other things that I hope the Minister will take a look at. Can we continue to improve availability at community level? Can we ensure that everybody receives the treatment set out in the National Institute for Health and Care Excellence guidelines? As I say, at the moment we are falling significantly short.

In conclusion, having set out those points—I could go on for much longer if we wanted—I hope that my speech highlights some of the real areas of concern. I also want to say a word about the voluntary groups; most of us in the field have become aware of the work of the very well-established Stroke Association, but we have a number of other groups, and in some cases entirely survivor-led groups give each other mutual self-support without any support from public funding.

I want to pay tribute to one group—frankly, the one that helps my wife and that she has received a great deal of assistance from being a member of. It is called Sidcup Speakability Group, and, as the name implies, it operates in our part of south-east London. It is the group’s 10th anniversary, so I just wanted to put on the record what it has done. It works entirely off its own back, and the level of conditions that people have varies greatly. But it proves that there is willingness. It is also worth remembering, as any senior consultant in the field will say, that there is sometimes a myth that a patient gets to a stage where they can never improve any more. Obviously, a patient has the best improvement earlier on. That is why early treatment and interventions are so important, and why the waiting times are so unacceptable. But even if the rate might be less, if people work continually, gains can still always be made incrementally. That is what the people at Speakability have found. To do that, we cannot expect the burden to fall simply upon friends and families. We need specialist treatment to be consistently available. That can turn people’s lives around. In our case, it may not be enough to turn it around in time, but it will be for others. That will be worth our while. The more people we can get back into work, as they wish, the more people can lead enriching lives, to a greater or lesser extent, as many stroke survivors do. There is light at the end of the tunnel, but we have to give them those fundamental services to start with.

I am very grateful to the Minister for paying great attention to the issue, and I hope he will take away those specific asks. Perhaps he could keep in touch with us, as a group, on how we could roll out services much more consistently and give people the level of treatment they deserve. I know a number of us in this room have been affected by stroke within our families, and I think we all want to work together—there is no party political issue in this—to have a proper strategy to sort it out.

[Mr Philip Hollobone (in the Chair)]

The debate can last until 10 minutes past 3. I am obliged to call the Scottish National party spokesperson no later than 2.37 pm. The guideline limits are 10 minutes for the SNP; 10 minutes for His Majesty’s Opposition; 10 minutes for the Minister; and then Sir Bob Neill will have three minutes to sum up at the end of the debate. We have half an hour of Backbench time, and I have to decide which of two stellar Members I should call first. I will go on the principle of ladies first, but also because I understand that the hon. Member for York Central (Rachael Maskell) is vice-chair of the all-party parliamentary group on stroke, so is probably far more qualified to talk about these issues than the delightful hon. Member for Strangford (Jim Shannon).

--- Later in debate ---

[Rachael Maskell]

Being able to undertake the diagnostic process really early means being able to get the information into the stroke unit of the hospital as early as possible, so that when the patient arrives at the door, they are whipped through the system and interventions can start. The problem is that we have such a time lag that intervention is often too late. Will the Minister look at what is happening on a global scale with interventions that could really make a difference?

Of course, there are two types of stroke: some people have a cerebral bleed and some have an infarct, or a blockage, where the brain is starved of oxygen. As a result, different treatments are undertaken. There is thrombolysis, which is a medical intervention to blast a clot through, and mechanical thrombectomy, which the hon. Member for Bromley and Chislehurst talked about, where a wire is fed through the femoral artery into the brain, captures the clot and withdraws it. As a result, the brain can receive the oxygen it needs so that it does not experience the damage that we have heard about.

We need to increase the specialist interventional neuroradiologist workforce. It is a highly trained specialism; we need enough of them, and a sufficient supply. We should have a workforce plan for the specialism to ensure we are training sufficiently and expanding the workforce. In other countries, there has been a real increase in the number of people able to access this treatment. As we have heard, the average across the UK is 3.3%, but in other countries it is 10%. Not all patients can benefit from this life-saving treatment, but of those who can, only about a third get access to it.

We need to think about where the centres are based. It is important that they are in major centres because doctors need to do a lot of these procedures to be expert in them. We need people to be expert in them, but we also need more centres. I ask the Minister to look at the mapping of that, and at specialist commissioning through NHS England to ensure provision right across the country. Will he also work with the ICBs in this area?

We need a specialist workforce. It is positive that we are training more people in stroke specialisms, but in physiotherapy, for example, significant further training is needed on Bobath—a technique used in stroke rehabilitation—and we need to ensure that it is easily accessible. Other professionals do not get the same access to training budgets as medics, so there is often a lag in getting people through the specialist training that is needed. I ask the Minister to look at that to ensure that the workforce is trained in the best techniques to treat stroke, and to carry that specialism.

This is all about investing to save money, because the better the intervention, the better the outcome for the patient. We need physios, occupational therapists, speech and language specialists—there is a significant shortage of them—and clinical psychologists to work as a team around the patient. They often work together. To give hon. Members an idea of how long it takes, a physio can spend an hour a day with a patient, because they have to break down and rebuild their tone and spasticity, which takes time. But as they are sitting the patient up, the speech therapist often comes along and does a swallow test, and an OT may do some function work. That team needs to come together. Unfortunately, the gaps in the workforce mean that it is hard to have the quality of treatment that will benefit the patient, from the most acute phases of the stroke right through to rehabilitation.

Of course, we want patients to go to stroke units—specialist rehabilitation places—where they can benefit from therapeutic intervention and get the best outcomes possible to optimise their baseline before they are discharged back home. Being in that environment is really important, but at the point of discharge, after all that cost—we have talked about diagnosis, intervention and therapy—what happens? Well, experiences are very varied, and 45% of survivors feel abandoned, so we know something is going wrong. Individuals can easily lose confidence and function.

If an individual is on a pathway to a care home, the care home should be properly trained in supporting people who have had a stroke. Everything matters: the person’s positioning, how they lie in bed, how they sit in a chair and how their hand rests can make a real difference to their function, and their hygiene and personal care. It is necessary to ensure that, if they are mobilising, it has an impact. How patients are transferred can make a difference to those outcomes, so it is important that a person is discharged not just to a care home, but to a care home that has undergone proper training. If someone is moving to the community, we need to ensure that the family around them are trained in how to support them, just as carers who provide domiciliary care must be.

I want to pick up on what the hon. Member for Bromley and Chislehurst said about people seeing improvements in their baseline functioning. It is possible that individuals do and will. Through the process of neuroplasticity, a person’s brain changes and can make alterations and repair, so we need to ensure that, when somebody gets home, there is ongoing therapeutic intervention. It is easy to slip into bad ways and take shortcuts, which can undo some of that good work, and those interventions to top people up can make a difference and keep people functional, mobile and independent. If people miss out on those interventions, they will rapidly require more acute care.

I draw the Minister’s attention to that and ask him to look at the whole pipeline. The lack of support is clear: only 37% of patients got their six-month check last year, which is completely insufficient. We need the figure to be 100%, so there is clearly some work for the Government to do. We are talking about 40,000 people who missed out altogether, which affects ongoing care and support. In the same way that a cancer care navigator works with patients, we need somebody who co-ordinates care and individual support on the stroke pathway, as a permanent process.

As I have already said, we have an opportunity next year to make a seismic difference to individuals by focusing on stroke. I hope that the Minister will take that opportunity, with a laser focus on a new stroke strategy across the country. If he does not, I will badger my hon. Friend the Member for Denton and Reddish to take that on, whenever he gets the first opportunity. It is important that we do that.

Finally, research in this area could be improved, and investment in research is needed. As we have seen in recent times, investment in thrombectomy has been a game changer. It gives people who experience a stroke real hope. Other interventions can and will be made: we need to understand more about our brain health, therapeutic interventions, and how to use new technologies to help people to be independent and live full and comprehensive lives. I trust that the Government will look at the research base and at investment in research as an opportunity. I trust that they will also work with the voluntary organisations that work so hard in this area—they are real experts—to ensure that we have the best stroke strategy and stroke outcomes that any country could ever have.

[Mr Philip Hollobone (in the Chair)]

No Westminster Hall debate would be complete without a contribution from Jim Shannon.